Doctors Tested by Undercover Patients

Many hospitals and clinics use undercover patients to evaluate physicians and staff, much as retailers use “secret shoppers” to assess salesclerks. At an upcoming meeting, the American Medical Association (AMA) House of Delegates will decide whether to endorse the controversial practice, with several preconditions.

Dr. Richard Frederick of the University of Illinois College of Medicine challenged the American Medical Association to re-examine the issue of secret patients. In Virtual Mentor, the AMA Journal of Ethics, Fredericks describes “sham patients” visiting congested emergency rooms feigning chest pain. He asks, “How could the hospital administration defend this exercise to someone who suffers an adverse outcome while waiting his turn behind the person who is only pretending to be sick?”

However, evidence of improvements following undercover studies at Beth Israel Deaconess Medical Center in Boston can’t be ignored. In two years, the center shortened the wait for an appointment from 12 days to three, enhanced communication with patients, and improved attention to patient privacy; customer service ratings also “jumped from 2.6 (fair) to 4.8 (excellent).”

In a March 2008 report, Canadian researchers uncovered gender bias among physicians who were consulted by male and female secret-shopper patients with “moderate knee osteoarthritis as close to identical as could be found.” Each met with 38 family doctors and 33 surgeons near Ontario, but the male patient was far more likely to be referred for surgery.

In 1993, Dateline NBC was widely criticized for broadcasting a segment featuring an undercover patient seeking treatment for cataract surgery; the eye center’s attorneys characterized the approach as “entrapment.”

WRAL.com, a North Carolina news site, reported that the American Medical Association plans to address specific concerns of doctors, like Dr. Fredericks, and plans to impose limitations so that “secret shopper” patients cannot interfere with service to real patients.

Dr. James Frederick favors postencounter surveys with real patients and other evaluation instruments over report cards from “sham patients.” He argued, “If these people are not sick, frightened, tired or vulnerable how helpful is their appraisal to the physician whose patients are frightened and vulnerable?”

Dr. James Loden, an ophthalmologist whose practice uses undercover patients, finds it “rewarding and insightful.” Loden said, “We must look to the retail industry at times for ideas on how to judge whether doctors and staff alike are delivering the care that clients, partners, and other staff members deserve.”

A report by AMA’s Council on Ethical and Judicial Affairs recommends that the AMA’s House of Delegates adopt a resolution in support of secret shopper “patients” properly trained to evaluate physician’s performance. The Council recommends several elements of any such program, including that (i) doctors be notified that secret shopper patients may visit; (ii) that information collected be used only to identify areas for improvement; and (iii) that secret shoppers never harm the care of legitimate patients, for instance by visiting a crowded emergency room.

Jayne Sheehan, senior vice president for ambulatory and emergency services at Beth Israel Deaconess Medical Center in Boston, assessed the effectiveness of secret visits after performance feedback had been given. Sheehan explained, “Shoppers awarded waiting room staff members an average score of 85, on a scale of 1 to 100, after a second round of visits this spring. That's an increase from 76 in January.”

Dateline NBC executives were soundly criticized in 1993 for sending an undercover patient to Southeastern Eye Center in North Carolina and broadcasting video footage in which a doctor discusses the possibility of cataract surgery, at which point a Dateline camera crew bursts in and confronts him. The Eye Center insisted on a public apology and a withdrawal of their statement. Time magazine reported, “Southeastern’s attorneys complain that not only was Caine’s aggressive pursuit of surgery unusual, it bordered on entrapment.” The parties issued a joint statement of clarification several months later.

Dorothy Aungier, the female patient in the Canadian research study measuring gender differences in doctors’ assessment and recommendations, reported, “It was amazing. Some doctors said ‘here’s some pills’ and gave me a prescription. One doctor said ‘just walk on grass.’” Gender bias has significant implications under Canada’s “single-payer” health system, where obtaining a second opinion can be difficult.